The Facts About Buprenorphine for Treatment of Opioid Addiction

the facts about BUPRENORPHINE

i “I’d been shot on the streets, I’d been in detox. It was jails, institutions…. Death, I knew, was imminent for me…so I started my recovery process…. It’s been 15 years since, and my life has never been better.” Walston B.

How do you escape from the misery and risks of drug addiction? Most people cannot do it on their own. They need help to return to normal, healthy living. One important form of help is called medication-assisted treatment. There are three, equally important parts to this form of treatment: • Medication • Counseling • Support from family and friends. Buprenorphine is one type of medication used for treatment of opioid addiction. Perhaps your doctor or substance abuse treatment provider has recommended it for you, or perhaps you already take it. This booklet gives you the facts you need to know. NOTE: Important words often used in treatment are introduced in this booklet in bold type.

ii Opioid addiction is a disease. Opioids are drugs that slow down the actions of the body, such as breathing and heartbeat. Opioids also affect the brain to increase pleasant feelings. They get their name from opium, a drug made from the poppy plant. Opioid medications are prescribed to treat pain and sometimes for other health problems such as severe coughing. Heroin is an illegal opioid that is smoked, snorted, or injected to get a good feeling, often called a “rush” or “high.” People also sometimes seek this feeling by taking large doses of prescription opioids. If you take opioids, you can become tolerant to them. This means that more of the drug is needed to obtain its effects. It is also possible to become dependent on opioids. This means that if you stop taking them, you will feel sick. This sickness is called withdrawal. Dependence is not the same as addiction, but sometimes dependence leads to addiction. The signs of addiction are: • Craving—The mind develops an overwhelming desire for the drug. • Loss of control—It becomes harder to say no to using the drug. Use is compulsive and continues even though the drug causes harm. Tolerance and dependence are common side effects of prescribed opioid medication that can be managed under a doctor’s care. Tolerance and dependence also are side effects from misuse of opioids. Addiction is not likely to develop in a person using medication properly, but this sometimes happens. Addiction usually occurs through misuse. Some people are at higher risk of addiction because of their genes, temperament, or personal situation.

1 Not everyone who uses opioids gets addicted. But it is difficult to stop using opioids after you have become addicted, because the cravings are so strong and the fear of withdrawal is so great.

Opioid addiction can be treated. Opioid addiction is a chronic disease, like heart disease or diabetes. A chronic disease is a medical condition for life. It cannot be cured, but it can be managed. A person with addiction can regain a healthy, productive life. But if you are like most people, you cannot walk away from addiction on your own. Treatment—the care of medical pro- fessionals and substance abuse treatment providers—can help. Treatment helps you give up the problem drug. It helps you get through withdrawal and cope with cravings. Treatment also helps you change addictive thinking into nonaddictive, healthful patterns. It can help you move away from other harmful behaviors, too, such as drinking alcohol or abusing other drugs besides the problem opioid. Just as important, treatment helps you address life issues you might have that are tied to the addiction, such as feelings of low self-worth, a bad situation at work or home, or spending time with people who use drugs. In short, treatment helps you move into a healthy, addiction-free lifestyle—into a way of living referred to as recovery.

Treatment may include medication. Medication-assisted treatment is treatment for addiction that includes the use of medication along with counseling and other support. Treatment that includes medication is often the best choice for opioid addiction.

2 If you are addicted, medication allows you to regain a normal state of mind, free of drug-induced highs and lows. It frees you from thinking all the time about the drug. It can reduce problems of withdrawal and craving. These changes can give you the chance you need to focus on the lifestyle changes that lead back to healthy living. Taking medication for opioid addiction is like taking medication to control heart disease or diabetes. It is NOT the same as substi- tuting one addictive drug for another. Used properly, the medication does NOT create a new addiction. It helps you manage your addiction so that the benefits of recovery can be maintained.

Buprenorphine is a medication used to treat opioid addiction. Buprenorphine is one of three medications commonly used to treat opioid addiction. The other two are methadone and naltrexone. Cost varies for the different medications. You may need to take this into account when considering your treatment options. The person who takes buprenorphine feels normal, not high. However, the brain thinks it is receiving the problem opioid, so withdrawal symptoms stay away. Buprenorphine also reduces cravings. If cravings continue to be a problem, your doctor will adjust your medication or help you find other ways to reduce them.

3 You take buprenorphine as a pill that dissolves under the tongue. You do NOT chew or swallow it. There are two forms. Suboxone® contains buprenorphine plus another medication called naloxone. The naloxone is added to prevent abuse—it brings on withdrawal in people who abuse buprenorphine by injecting it. Subutex® contains only buprenorphine. This form is prescribed if you should not take naloxone for any reason, such as if you are allergic to it or are pregnant. The pill is taken once a day. Over time, the dose interval may stay at once a day or change to every other day. The main advantages of buprenorphine are: • You are unlikely to overdose on buprenorphine if you take it properly. • Buprenorphine is long acting. This means that after an initial period, your doctor may have you take the pill every other day rather than once a day. • Doctors can prescribe buprenorphine so that you can take doses at home. Important: Not all doctors have approval to prescribe this medication, and not all doctors provide counseling for addiction. Also, daily check-in at a treatment center can be helpful to recovery. Therefore, for some people, a treatment center is the best place to receive medication for opioid addiction.

Buprenorphine may be prescribed if it is the right choice for you. Before you are given the first dose of any medication for opioid addiction, your doctor will ask you questions about your addiction, health, and other problems. You will get a drug test—usually a check of urine or saliva. You also will have a physical exam and tests for diseases that are common to people who have been

44 abusing drugs. Your liver will be checked to make sure the medication can be safely taken. If buprenorphine is safe and appropriate for you, your doctor may recommend it. You and your doctor or substance abuse treatment provider decide together on a treatment plan. The plan describes the medication routine, the counseling and other services that will be provided, and the rules that must be followed. These rules will be explained to you and you will get them in writing.

Buprenorphine must be used carefully. Your doctor will prescribe a low dose to start taking after withdrawal symptoms begin. Dose levels may be adjusted up as needed. Always take doses exactly as prescribed by your doctor. Buprenorphine can make you feel drowsy at first. You should not drive or perform other high-risk tasks until you know how this medication affects you. If drowsiness continues to be a problem, your doctor may adjust dose levels. You may take buprenorphine for days, months, or years—as long as it is needed to prevent relapse. However, you should be checked often by a doctor if you have liver disease. If you are stable in recovery and want to stop taking buprenorphine, you must do it slowly, over time. This is called tapering. Tapering works best with the help of your doctor or substance abuse treatment provider, after progress has been made in treatment.

5 WARNINGS • While taking this medication, you should NOT take other medications without consulting your doctor first. • While taking this medication, you should NOT use illegal drugs, drink alcohol, or take sedatives, tranquilizers, or other drugs that slow breathing. Taking any of these substances in large amounts along with buprenorphine can lead to overdose or death. • Buprenorphine kept at home must be locked in a safe place to prevent accidental use by others, especially children. • If you are a woman and are pregnant or breast-feeding, methadone is safer than buprenorphine for mother and child. In special circumstances, doctors may recommend the naloxone-free form of buprenorphine instead of methadone. Ask your doctor for more information. • Liver problems are rare but can occur. If you have a pre-existing liver condition, your doctor should conduct regular tests on your liver.

Buprenorphine has side effects in some people. Side effects are feelings of discomfort or sickness that come with taking medicine. Buprenorphine has a few mild side effects. Usually these go away after the medication is taken for a while. If you have side effects, you should NOT stop taking the medication. Instead, talk with your doctor or substance abuse treatment provider. An adjustment in dosage or a change in medication may help. There are some simple things you can do to reduce side effects, too.

6 COMMON SIDE EFFECTS AND SIMPLE WAYS TO REDUCE THEM Body aches, headaches, and cold- or flu-like symptoms— Check with your doctor about over-the-counter medicines you may take. Dizziness—Stand up slowly. Call your doctor if problems persist. Constipation—Drink more water and juice. Eat food with fiber. Exercise more. Sweating—Shower often. Dress in layers. Sleep problems, including tiredness—Take the pill in the morning. Avoid naps. Go to bed at the same time every night. Exercise. Do not drink caffeine after lunchtime. Upset stomach or vomiting—Take the pill after you have eaten. Take an antacid product as directed by your doctor. Mood swings—Exercise more. Do fun things that do not involve the old drug lifestyle. Relax. Talk to your substance abuse treatment provider. Serious side effects—For extreme stomach pain, vomiting, or diarrhea, contact your doctor right away. Also seek help if the following side effects appear, because they may indicate serious liver problems: • Dark or tea-colored urine • Bad stomachache • Light-colored bowel movements • Yellowing in the whites of the eyes • Yellow skin.

7 Counseling can help. Medication is one part of treatment for opioid addiction. For many people, another important part is counseling: the opportunity to talk with a professional either one-on-one or in a group with others in treatment. Through counseling, you learn about the motivations and behaviors that led to your opioid addiction. You learn how to commit to a more healthful lifestyle. You gain support and skills while working with others to manage your recovery long term. Counseling can provide you with encouragement and with motivation to stick to treatment. It can help you learn how to make healthy decisions, handle setbacks and stress, and move forward with your life. In group counseling, you connect with others in treatment and make new friends who don’t use drugs. You can get these benefits from support groups, too. These are informal meetings of people facing similar challenges.

88 Family and friends are important, too. It is very hard to go through recovery alone. Support from family and friends is very important. Love and encouragement can help you make the decision to enter treatment and stick with it. Some treatment programs offer counseling for your loved ones. They do this because your addiction may have caused pain and anger or feelings of shame and hopelessness. Counseling is a useful way for family and friends to learn more about your situation, how to help, and how to handle the problems your addiction has caused them. It is a safe place for them to express feelings and to find out what help is available for everyone affected. There are support groups for family and friends, too. These are safe places to share information and encourage others who have loved ones who are dealing with addiction.

Many people with an opioid addiction regain normal, healthy lives. One way they do this is with medication-assisted treatment. Medication, counseling, and support: together they can help you, your loved ones, and your friends.

“The treatment center that I was at had a lot of education about addiction. They talked about it as a disease and not a moral failing…. I had a medical condition…. And that was a big relief for me to hear that and to be able to realize that recovery was possible.” Tom C.

9 The Facts 10 treatment andbeyond. again. Recovery takescommitmenteveryday, through ment isfinished,everythingNOTautomatically fine Recovery ispossible. treatment provider. your privacyrights,talktosubstance abuse into treatmentbythecourts.To learnmoreabout yourself orothersand(2)ifyouhavebeen ordered privacy rule:(1)ifitappearsthatyoumayharm with others.Therearetwoexceptionstothis writing) beforesharinginformationaboutyou obtain yourinformedconsent(agreementin A substanceabusetreatmentprovidermust problem opioid. trolled levelofmedicationtoovercometheusea addictive drugwithanother. Itprovidesasafe,con- recover fromaddiction. The goalofmedication-assistedtreatmentisto addiction isto“bestrong.” weakness. ItisNOTTRUEthatallyouneedtokick from familyandfriends.AddictionisNOTasignof be treatedwithmedication,counseling,andsupport Addiction isadisease.Itcannotbecured,butitcan WHAT’S TRUEANDWHAT’S NOT ADDICTION

Butittakeswork.Aftertreat ItdoesNOTreplaceone - BUPRENORPHINE WHAT’S TRUE AND WHAT’S NOT Buprenorphine helps you think and function normally. It is legal and taken under a doctor’s care. It is NOT just another drug to abuse. Buprenorphine is produced under safe condi- tions and sold legally. There is no risk of getting tainted doses, which can happen with street drugs. Also, risk of overdose on this medication is very small. The Facts You can stop taking buprenorphine when you are ready. You can become dependent on buprenorphine, as with many medications taken over time. For this reason, if you wish to stop taking buprenorphine, you should work with a substance abuse treatment provider to taper off. This prevents withdrawal symptoms from appearing.

11 Support groups and information • This is not a complete list. Listing here does not mean that the Substance Abuse and Mental Health Services Administra- tion (SAMHSA) endorses any of the organizations. • Some support groups have abstinence-only policies and do not look favorably on medication-assisted treatment. The programs listed here do not have such policies, but individual group meetings vary. You may need to try several support groups to find the right one. • Some support programs are just for people with a substance use disorder, and others allow families and friends to attend meetings or have separate meetings for them. Check with each organization for details. • An Internet-based support group may be your best option if no groups meet in your community. Another option is to contact Alcoholics Anonymous (AA, http://www.aa.org) to find out whether AA meetings in your community are open to people in recovery from other substances besides alcohol.

Dual Recovery Anonymous http://www.draonline.org or 913-991-2702 LifeRing http://lifering.org or 800-811-4142 National Alliance of Advocates for Buprenorphine Treatment http://www.naabt.org Rational Recovery http://www.rational.org or 530-621-4374 Secular Organizations for Sobriety http://www.sossobriety.org/home.html or 323-666-4295

1212 SMART Recovery http://www.smartrecovery.org or 866-951-5357 Women for Sobriety, Inc. http://www.womenforsobriety.org or 215-536-8026

Buprenorphine physicians and treatment program locator 800-662-HELP (4357) (English and Español) 800-487-4889 TDD (for hearing impaired) http://buprenorphine.samhsa.gov/bwns_locator/index.html

Free booklets • The Facts About Naltrexone for Treatment of Opioid Addiction (also in Spanish) • Medication-Assisted Treatment for Opioid Addiction: Facts for Families and Friends (also in Spanish) • What Every Individual Needs To Know About Methadone Maintenance Treatment: Introduction to Methadone • Faces of Change: An Illustrated Booklet for Consumers • What Is Substance Abuse Treatment? A Booklet for Families (also in Spanish) • Motivation for Change: John’s Story–Consequences of His Heavy Drinking and His Recovery (also in Spanish)

Electronic access and printed copies This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

13 “What I’ve found in my life is that the more people I know that I tell that I’m a person in recovery…, then the more people will be able to carry that message to their friends and family and say, ‘Hey, I know somebody who doesn’t use drugs anymore who used to, and his life has gotten better. Maybe you can give this a try.’”— Dan P.

ACKNOWLEDGMENTS This publication was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., under contract number 270-04- 7049, with SAMHSA, U.S. Department of Health and Human Services (HHS). Christina Currier served as the Government Project Officer.

All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without specific written authorization from the Office of Communications, SAMHSA, HHS. This publication may be ordered or downloaded from SAMHSA’s Publications Ordering Web page at http://store.samhsa.gov. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

HHS Publication No. (SMA) 14-4442 First Printed 2009 Revised 2011 and 2014